Immigration information for IMGs

General Eligibility for IMGs IMGs who seek entry into U.S. programs of Graduate Medical Education (GME), must obtain a visa that permits clinical training to provide medical services.

Obtaining a Visa

J-1 Exchange Visitor Program and ECFMG SponsorshipThe most common visa used to participate in U.S. graduate medical education programs is the J-1 visa. The Educational Commission on Foreign Medical Graduates (ECFMG) is authorized by the U.S. Department of State to sponsor foreign national physicians for the J-1 visa. Information on eligibility and deadlines is available from ECFMG's Exchange Visitor Sponsorship Program.

To apply for a J-1 visa, an IMG must have passed the USMLE Step 1 and Step 2 CK (or equivalent), have a valid Standard ECFMG Certificate (without unexpired examination dates, if applicable) at the time of commencement of training, hold a contract or an official letter of offer for a position in a program of graduate medical education or training that is affiliated with a medical school, and provide a statement of need from the Ministry of Health of the country of last legal permanent residence (LPR) regardless of country of citizenship.

Two-Year Home Country Physical Presence RequirementUpon completion of training, they must return to their home country for a period of two years to transmit the knowledge they gained in the U.S. An individual must fulfill (or obtain a waiver of) this obligation before being eligible for a change or adjustment of visa status to certain types of US visas. These visa types include H, temporary worker; L, intra-company transferee; and US permanent resident.

J-1 Visa Waivers The only exception to the two-year home residence requirement of the J-1 visa program is receipt of a waiver. Under the law, the following three circumstances are the only ones that provide for waiver of the two-year residency requirement:

1. If the waiver applicant can demonstrate that he or she will suffer from persecution in his or her home country or country of last legal permanent residence;

2. If fulfillment of the residency requirement would bring proven exceptional hardship to the applicant's spouse and/or children who are U.S. citizens or permanent residents;

3. If the applicant is sponsored by an interested governmental agency (IGA) which is interested in the physicianÆs continued employment in the U.S.

Since waivers based on expected persecution or hardship are very rare, most IMGs receive waivers by finding an IGA to sponsor them. Traditionally, the Department of Health and Human Services (DHHS), the Department of Veterans Affairs (VA) and the Appalachian Regional Commission (ARC) were the agencies that sponsored IMGs for J-1 waivers. Recently, the Department of Agriculture (USDA) and the Department of Housing and Urban Development (HUD) began to sponsor IMGs for waivers. In addition, through the Conrad-30 program sponsored by Senator Kent Conrad of North Dakota, state departments of public health may sponsor up to 30 J-1 physicians per year for waivers to provide care in underserved communities.

On December 3, 2004, President Bush signed into law an AHA-backed bill (S. 2302) that extends the State 30/J-1 Visa Waiver Program for two years. The program, which expired in June, allows state health agencies to annual hire up to 30 J-1 foreign physicians to practice in rural and inner-city communities with physician shortages. It waives the requirement that foreign physicians who have completed their residencies in this country return home for two years before they can apply for an immigrant visa. Physicians selected for the waivers can apply for an immigrant visa. Physicians selected for the waivers can practice in primary care or specialty medicine, if a local shortage in the requested specialty can be demonstrated, and are exempt from caps on H1-B visas. Up to five doctors selected in each state can work in regions not specifically designated as underserved by the Department of Health and Human Services.

To enter and remain in the U.S. as a non-immigrant or immigrant requires several steps. First, a foreign citizen or his or her employer or relative must file an application with the Department of Homeland Security (DHS) to be classified in one of the non-immigrant or immigrant visa categories. If the DHS approves the application, the foreign applicant may need to go to a U.S. embassy or consulate overseas to have a visa stamped in his or her passport. This stamp indicates the visa category and the dates of issuance and expiration. At the U.S. border, an immigration inspector will review the visa stamp and issue an admission card. The inspector can authorize admission for any length of time up to the expiration date on the visa stamp. U.S. Citizenship and Immigration Services also issues permanent resident alien cards to immigrants in the U.S.

Most of the approximately 50% of IMGs who are not U.S. citizens or permanent residents enter the U.S. on a J-1 Exchange Visitor visa or an H-1B visa.

Temporary Worker H-1B The H-1B visa is for temporary workers in speciality occupations who hold professional-level degrees. The Immigration Act of 1990, and subsequent technical amendments, made the H-1B available to graduates of foreign medical shools who have passed FLEX or the equivalent, have passed an English language exam, and hold a license appropriate to the activity. The advantage of the H-1B visa is that it has no two-year home residence requirement, as does the J-1. The H-1B allows a foreign national to enter the U.S. for professional level employment for up to six years.

H-1B employment authorization is employer specific. The GME program must file an H-1B petition on behalf of the IMG; the law does not permit prospective trainees to file for themselves. To qualify for an H-1B, an IMG must be in possession of a full, unrestricted state medical license or the appropriate authorization for the position, an MD or full unrestricted foreign medical license, English language competence as established by passage of the ECFMG English language examination and passage of the USMLE Steps 1, 2 and 3.

F-1 Student Optional Practical Training The INS grants H-1B visas to temporary professional workers who are required to have a prearranged job, either temporary or permanent, in a professional field before they receive a visa. There is an initial admissions period of three years, with the possibility of extending oneÆs stay for a second three-year period. After staying in the U.S. for the maximum six-year period, a foreign citizen is required to live abroad for one year before re-entering the U.S. in an H or L visa category.

An H-3 visa is granted to a trainee who is a foreign citizen coming to the U.S. temporarily to receive training not obtainable in his or her home country. After receiving this training in the U.S., those on an H-3 visa must use the skills gained in the U.S. in a foreign country.

Immigrant Visas An immigrant visa (also known as a green card or permanent resident status) permits a foreign citizen to permanently remain in the U.S. A lawful permanent resident (LPR) has the right to become a naturalized U.S. citizen after living in the U.S. for three to five years. To obtain immigrant status, an applicant must meet the requirements of the law. One must qualify as a specified immediate relative of a U.S. citizen or another LPR, as an employee of a sponsoring employer or prospective employer, or as a "diversity immigrant" under a visa lottery program. Moreover, the applicant must not fall into any of the categories of aliens deemed inadmissible by law, including criminality, mental defect, Communist party affiliation, drug trafficking, or terrorism. Generally, IMGs only qualify for permanent resident status based on an existing employment position.

Once an IMG receives a J-1 waiver and a state medical license, he or she may obtain a new work authorized status for U.S. employment, which in most cases will be an H-1B visa or an immigrant visa. Often, the H-1B or immigrant visa process may be concurrent with the J-1 waiver process. The H-1B visa and some types of immigrant visa petitions require a filing with the Department of Labor in addition to the INS. Normally, IMGs may not change from J-1 to H-1 status in the U.S., but must travel abroad to a U.S. consulate to obtain visa issuance. In contrast, IMGs can move directly from J-1 status to immigrant status without leaving the U.S.

There are several different options for IMGs wishing to become permanent residents in the U.S. In previous years, many IMGs qualified for permanent residence based on the national interest waiver classification. That is, IMGs whose continued residence and employment in the U.S. benefited the national interest, for example by working in an underserved community, qualified for an expedited permanent residency process. However, many physicians do not qualify for residency based on a national interest waiver for a variety of reasons including location of practice and medical specialty practice.

In these cases, obtaining permanent resident status becomes a much more arduous process. The most prevalent of the other available options is for the IMGÆs employer to go through the labor certification process, which requires the employer to certify that employment of the IMG will not be detrimental to the U.S. labor market and that he or she is the only fully qualified candidate for the position. The Department of Labor (DOL) conducts this process, which tends to very complex and time-consuming. Due to a number of factors, processing of Labor Certification Applications can take from one to two years. However, on October 1, 1997, the DOL announced revisions to the application process, which have the possibility of streamlining the process for IMGs by requiring less stringent documentation of the recruitment process for a U.S. candidate for the position and by requiring expedited treatment of cases for which there are few or no U.S. applicants. Once the Labor Certification Application is completed and approved by the DOL, the employer must submit an Immigrant Visa Petition to the INS. Upon approval of this Petition, the IMG may finally apply for permanent residence through the INS or a U.S. consulate abroad.

The final option available to IMGs who wish to obtain permanent residence is available to physicians of extremely high professional capacity who qualify for an accelerated process established for Aliens of Extraordinary Ability or for Outstanding Professors or Researchers.

The national interest waiver pathway to permanent residence is the least complex and most time-efficient for IMGs. Applications under the national interest waiver program can be processed in a 60-90 day period, representing a significant reduction of time spent in the immigration process. Two other major advantages are the ability of the physician, in addition to the employer, to file the request and increased freedom to change employers. However, this waiver program does impose other restrictions which applicants should explore before proceeding.